A Primary Care Therapeutic Alliance? Love in the Doctor-Patient Relationship

file1141234819793Recently I had the opportunity to have a conversation with Dr. Marc Braman, a national leader in “lifestyle medicine.” Marc’s an integrative, out-of-the-box thinker. He’s dedicated to serving his patients well and has decades of experience in helping patients to change for the better. Naturally, I asked him to tell me how he goes about it. So how do you help people give up bad habits and adopt new health behaviors? Marc, what’s your secret to that?

Of course, there is no secret knowledge, but Marc replied that it was critically important to form a strong and committed relationship with the patient. He likened it to the “therapeutic alliance” concept used in psychotherapy. Marc tells his patients plainly that he won’t judge or condemn them for their habits (say smoking) and won’t harangue or badger them to change. From the first appointment, he seeks to create a relationship of mutual trust and commitment where it’s safe for patients to be honest with him, and he can, over time, help them make positive changes.

We went on to share more of our ideas and experiences, but this particular idea of a “primary care therapeutic alliance” struck a chord with me, and I’ve been thinking about it a lot since then. My first thoughts went to Dr. Scott Peck’s description of the therapeutic alliance in his best-selling book The Road Less Traveled. He had this to say:

Genuine love, on the other hand, implies commitment and the exercise of wisdom. When we are concerned for someone’s spiritual growth, we know that a lack of commitment is likely to be harmful and that commitment to that person is probably necessary for us to manifest our concern effectively. It is for this reason that commitment is the cornerstone of the psychotherapeutic relationship. It is almost impossible for a patient to experience significant personality growth without a “therapeutic alliance” with the therapist. In other words, before the patient can risk major change he or she must feel the strength and security that come from believing that the therapist is the patient’s constant and stable ally. For this alliance to occur the therapist must demonstrate to the patient, usually over a considerable length of time, the consistent and steadfast caring that can arise only from a capacity for commitment. [emphasis mine]

I believe Dr. Braman has identified a very significant issue. How committed and non-judgmental is the average doctor with respect to the average patient these days? It seems to me, that if we’re not careful to guard against it, we’re pretty likely to find ourselves blaming and shaming the patient. What does the term “noncompliant” imply about the patient and the nature of the doctor-patient relationship? Should we ever dismiss patients for “noncompliance” or missing appointments?

Beyond the attitudes and behavior of the individual physician or other healthcare provider, how is the system working to foster such therapeutic alliances? Not very well. An individual’s insurance coverage often changes from year to year, necessitating a change in their doctors. Or the insurance company drops a physician from their panel. Or, in reverse, the physician drops the insurer. Or the doctor joins a new practice across town. Provider networks are not stable these days.

Clinic practice methods are not stable either. Financial pressures in healthcare are forcing a trend for providers to operate at “the top of their licenses.” This means, doctors only do what only a doctor can do. Let someone of lesser training and scope of licensure do the other things. Sounds nice in concept, but it certainly doesn’t make for strong doctor-patient relationships. Taken to its logical extreme, why ask doctors to talk with patients about their lifestyles at all? Let the health coach do it. It doesn’t take a medical license to help someone change his or her lifestyle.

So what do we do? I don’t know. Some of the structural shifts in healthcare (like “top of license”) that interfere with relationships aren’t going away. I do think that provider networks will become much more stable over time. Maybe the design of the system will not allow for the typical patient to have a therapeutic alliance with his or her doctor. But patients need a therapeutic alliance with someone! The patient needs a constant, stable, loving ally from within the healthcare system. It may not have to be the doctor, but if not the doctor, then who? Could it be a health coach, ARNP or social worker? Possibly. I think it depends on the individual person as much as the degree or training.

As a healthcare leader, I’m asking myself some questions – How do we design therapeutic relationships into our healthcare system? Where will healing happen in the future system we’re building? How do we love our patients like Jesus loves us? If you’ve got ideas, I’d love to hear them.